Wednesday 21st September - Leeds

Transcription

1 Diane Leach

2 Wednesday 21st September - Leeds

3 Outline of presentation Treatment options Types of urinary diversion Radical cystectomy and ileal conduit Patient counselling Care of the stoma Types of appliances Discharge and follow up

4 Treatment options: BCG Neo adjuvant chemotherapy Radiotherapy Surgery

5 Types of urinary diversion: Radical cystectomy and ileal conduit Radical cystectomy and orthotopic neo-bladder formation Pelvic exenteration Cutaneous ureterostomy Nephrostomy Radical cystectomy and mitrofanoff formation

6 Examples of urinary diversions

7 Cutaneous ureterostomy Ureters are excised from the bladder and brought through the abdominal wall to form stoma. Advantages: Not considered major surgery Disadvantages: External collecting device must be worn. Possibility of stricture or stenosis of small stoma.

8 Nephrostomy Catheter is inserted into the pelvis of the kidney. May be done on one or both kidneys and may be temporary or permanent. Most frequently done in advanced disease as a palliative measure. Advantage: No need for major surgery Disadvantage: High risk of renal infection. Predisposition to calculus formation from catheter. May have to be changed every month. Catheter should not be clamped, should remain open.

9 Cystectomy and orthotopic neobladder formation

10 Radical cystectomy and ileal conduit

11 Counselling Clinics We allow a 60 minute slot Patients receive a pre-operative pack containing: 1. Booklet about urostomys 2. A pre-operative practice pack 3. Patient DVD How to care for your urostomy 4. Information regarding the urostomy association. 5. Enhanced Recovery booklet for Admission

12 Patient counselling Studies show that the vast majority of patients want to have as much information as possible regarding their disease. ( Cox et al, 2006, Rutten et al, 2005, and Jenkins et al, 2001).

13 Factors that may influence patient consultations: Age Gender Ethnicity Education Level Complexity of information required Sometimes we assume what the patient wants to know and it is not always what the patient needs ( Snyder et al, 2007)

14 Remember A well informed patients adjusts better to the entire post-operative experience and longterm management goals then who have not. Evidence suggests that preoperative information plays a valuable role in reducing postoperative pain and anxiety and in aiding faster recovery. Oshodi (2007)

15 Care of the urostomy Clean around the stoma with warm water Remove any mucus If stents are in situ check that they are patent and draining.

16 Care of the urostomy Check the peristomal skin for any redness or excoriation. Apply accessories if required, i.e. barrier wipe for red or excoriated skin Orahesive powder for broken skin Check size of template for flange Apply the cut out flange If a two piece system attach bag to flange

17 Flange template

18 Ureteric Stents

19 Ureteric stents protruding through the urostomy

20 Equipment for a bag change

21 Types of appliances Two piece system Advantages: Doctors can check the stoma by unclipping the bag and not disturbing the flange. Flange can stay on for 2-3 days and the bag can be changed as required. (we recommend daily). The position of the bag can be changed for connection to the overnight bag.

22 Types of appliances One piece system Advantages: Maybe easier for patients to apply especially if they have poor dexterity. It s a flatter bag so may be preferred by people who wear tight clothing. (We recommend changing this daily).

23 Possible complications post-operatively Small spouted or flush stoma Stoma on tension dips or in a moat Para stomal hernia Mucocutaneous separation Poor position and not where sited Necrotic stoma Oedematous stoma

24 Types of stoma

25 Mucocutaneous separation

26 Parastomal hernia

27 Poorly sited stomas

28 Stomal necrosis

29 Stomal oedema Ileal conduit stoma oedema will begin to subside within 7 days after surgery and continue to decrease in size gradually for the next 6 to 8 weeks.

30 Problem solving Convex flange or seal Orahesive powder or stomahesive paste.

31 Discharge and Follow up Patients should be independent with their care on discharge 2 weeks supply of products given to take home In Sheffield we refer to an independent delivery company

32 Discharge and Follow up Delivery Company will deliver any product ordered, cut flanges to required size and give complimentary items such as toiletry bags, dry wipes and disposal bags. They also provide community stoma care nurse follow up. Patients return to see the consultant in 6week follow up to discuss histology

33 Thank you for listening Any Questions????